B&B Exam 2 -- Mood/Anxiety, Brainstem, Brain Infxs

Classical Conditioning -- define: - Neutral Stimulus (NS) - Unconditioned stimulus (US) - Unconditioned response (UR) - Conditioned stimulus (CS) - Conditioned response (CR) What would each be in this experiment? Baby Albert is exposed to a mouse and has no reaction. Separately, there's a loud hammer noise that scares him. Then they expose Albert to the mouse and bang the hammer at the same time multiple times. Now Albert cries when he sees the mouse, even in the absence of the hammer.

e.g., PTSD Classical Conditioning in Iraq Going to a Bagdad market (NS) gets you shot at (US) which causes fear response (UR) After a 12 month tour of "conditioning" Going to any market (CS), even in Little Rock ("stimulus generalization"), leads to fear response (CR)

Nefazodone -bad SE that has made it rare

hepatic failure as SE

People with PTSD develop higher or lower levels of cortisol?

lower "too much NE and not enough cortisol" Simplistic, but likely a part of PTSD physiology

Fluvoxamine (Luvox) -drug class -only implemented for the treatment of ___

luvox SSRI Treats *OCD* -- no implications for Depression oddly enough. Might be because it inhibits a different Cytochrome P450 than others.... Inhibits Cytochrome P-450 *3A4* Side effects GI - nausea/vomiting/diarrhea SEXUAL (less than paxil and prozac)

Body Dysmorphic Disorder (BDD) -not considered OCD, but they do have behaviors such as what? -Frequently show up in what type of clinic?

obsession with some perceived flaw or flaws in one's appearance plastic surgeons Big example: Body Builders ==> Muscle Dysmorphia

Paroxetine -drug class -pretty bad withdrawal -- why? -- Unique feature: Paxil has the ... ... of all the SSRIs. -primary SE

paxil SSRI Shortest half-life (pretty bad w/drawal) Inhibits Cytochrome P-450 2D6 - strong > beware of interactions Sedating -- might be good for insomnia / anxiety Side effects GI - nausea/vomiting/diarrhea *SEXUAL*, prozac and paxil are the 2 really bad ones (mnem: PP won't work).

Fluoxetine

prozac longest half-life (less w/drawal sxs) Inhibits Cytochrome P-450 2D6 - strong > beware of interactions Side effects GI - nausea/vomiting/diarrhea Insomnia Jitteriness, increased anxiety, may precipitate panic attacks *SEXUAL*

Depression with Anxious Distress (specifier)

w/: Tension Restlessness Impaired concentration due to worry Fear that something awful may happen Fear of losing self-control

Sertraline

zoloft Inhibits Cytochrome P-450 2D6 - weak SEXUAL (less than paxil and prozac)

CO2 / False Suffocation Theory of Panic DO Effect of sodium *Lactate* and bicarbonate infusion on panic DO pts.

• People with Panic DO had panic attacks when injcted with sodium lactate or bicarbonate, which raise CO2 in blood. Controls did not. • Thus, CO2 induces panic attacks only in people with Panic DO. • So maybe, they are hyper-sensitive to CO2, lactate, and bicarbonate. • More CO2 receptors on brainstem; a lot CO2 receptor activity naturally tells the brain that you need more oxygen. So even though they are getting plenty of oxygen, they feel like they are suffocating. • More evidence: People with panic DO often have chronic hyperventilation (need more O2). • So even though they are getting enough O2, something in their brain is saying BREATHE FASTER, YOU'RE RUNNING OUT OF BREATH!! GET MORE OXYGEN!!

Agoraphobia Diagnostic Criteria

■ Anxiety comes from being in situations where escape would be difficult or unable to get help if they became anxious. ■ Such situations are avoided, endured with distress, or require presence of loved one.

Vortioxetine

(Trintellix) Serotonin modulator and stimulator

Other Depression Specifiers-- what's it called when: 1) Persistent milder depression (3 or more sxs) for at least 2 years 2) Temper outbursts that are inconsistent with developmental level. 3) physical, emotional, behavioral, and cognitive symptoms that begin in the luteal phase (second half) of the menstrual cycle and resolve shortly after the onset of menses (the follicular phase)

1) *Persistent depressive disorder (Dysthymia)* 2) *Disruptive mood dysregulation disorder* 3) *Premenstrual dysphoric disorder*

Psychiatric Lymbic System: WHAT TO KNOW 1) The *Anterior Cingulate Cortex (ACC)*: -location in the brain means it has connections to both __ and __ (parts of the brain). -What is its major role? 2) The *Amygdala's* role and status in *PTSD* 3) The *Dopamine Reward Pathway*: -involves *WHAT 2 main structures* for Dopa production, and in *WHAT ORDER*? (starting with the pleasurable stimulus)

1) It has a unique location in the brain, with connections to both the limbic system and the prefrontal cortex. Thus, it likely plays a role in SELF-REGULATING EMOTIONS, communicating between the emotional and logical regions of the brain. It also has connections to the hippocampus (emotion and memory) and to the brainstem (autonomic functions --- possibly related to stress!) 2) Hyperactivity of the amygdala in response to fearful faces predicts the extent of PTSD symptomatology. Hypersensitivity of the amygdala is a STRONG predictor of PTSD vulnerability. 3) pleasurable stimulus ==> *Ventral Tegmental Area (VTA)* ==> *Nucleus Acumbens (NAc)* ==> dopamine reward interpretation in the frontal lobe.

Name the depression specifiers: usually "*Depression with ___ features*". 1. -KEY: *Tends to wake up 2 hours early than normal* -they are just even more sad -- marked by profound despondency, despair, or gloominess. They usually even look very sad to other people. 2. -only happens at certain times of year -*what therapy* really helps them? 3. Also has delusions and/or hallucinations 4. Occurs either during pregnancy or within 4 weeks of childbirth.

1. Depression with *Melancholic* Features. 2. Depression *with Seasonal Pattern* 3. Depression *with Psychotic Features* 4. *Peri-partum* Depression

3 Best Treatments for GAD (2 medications, 1 therapeutic)

1. SSRI's / Venlafaxine 2. Buspirone 3. Cognitive-Behavioral Therapy benzos are 2nd to 3rd line

Panic attack sxs develop abruptly and usually peak within ___ minutes.

10 minutes

-PTSD vs Acute Stress Disorder -PTSD DSM5 criteria

>1 month vs <1 month

+++++++ *Ramelteon* -MoA -Side effect -It is only used to treat ___. -potential for abuse?

Agonist of melatonin receptors (MT-1 and MT-2), producing a sedative effect.

2/3 main parts of brain associated with PTSD -how does each play a role in the fear response, relative to each other, and what would you observe in these parts of the brain in PTSD pts?

Amygdala Medial Prefrontal Cortex (aka Anterior Cingulate Cortex) ^ regulates the amygdala -- slows it down Observations in PTSD pts: High amygdala activity, smaller ACC, low medial prefrontal cortex activity. ACC (involved in rational decision-making) is smaller in PTSD pts. Thus lower mPFC activity, which lets the amygdala run wild. NE is the NT responsible -- think of it as an "adrenaline surge"

How does the normal fear response occur? What part of the brain starts it?

Amygdala starts it -- sends info to medial prefrontal cortex (mPFC) which determines if its worthy or not of fear. If so, signal is sent to brainstem -- the locus ceoruleus in the pons -- which releases NE. Then you get fear. So NE is directly responsible for the fear.

What are 2D6 inhibitors?

Antidepressants that inhibit Cytochrome P-450 2D6. Most, but not all, are SSRIs. -Red = strong inhibitor (yellow = moderate, green = mild) -With strong 2D6 inhibitors, you need to be mindful of possible drug interactions! Some big ones to know: - SSRIs- Fluoxetine (worst for sexual SEs), Fluvoxamine (OCD only), Paroxetine (sedating), Sertraline, Citalopram (inc. QTc interval but fewer sexual SEs), Escitalopram, Duloxetine (nausea). - Non-SSRIs- Buproprion (Selective NDRI) and Vortioxetine (M of A unknown)

The OCD Brain: What is the 3-membered brain circuit that is hyperactive in OCD?

BLO circuit -- orbitofrontal cortex, limbic system (amygdala), and basal ganglia.

PTSD Symptom: Intrusion What is the general gist of intrusions? How does this show up in children?

Basically, intrusions are all the way that the event *disturbs* your mind. > Distressing memories > Recurrent distressing dreams > Dissociative reactions (e.g., flashbacks) > Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). > Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Bipolar I vs II DO - Dx Criteria

Bipolar Type II: -One hypomanic episode -One major depressive episode -Never had a manic episode If you've ever had a manic episode, you're Type I Type 1 does not require depression either -- a manic episode is the ONLY required dx. But usually, the pt will develop a subsequent depressive episode. i.e., people with bipolar disorder often also have episodes of depression. Sometimes these are severe enough to be called "major depression." But it is not required.

What is the best known treatment for specific phobias?

CBT (remember, CBT is always a good guess if you don't know!)

*Prazosin* for PTSD

CONTROL NIGHT MARES HELP SLEEP One study found no significant differences in any outcome measures.

What is the only SSRI approved for children and adolescent depression?

Fluoxetine -- prozac

Difference between benzos and barbs in terms of effect on GABA receptor. What are Z drugs? Z-drugs require the presence of which GABA receptor subunit?

GABA receptor has 2 alphas, 2 betas, and one gamma component. Barbiturates, benzodiazepines and "Z-drugs" (and alcohol) all work via increased GABA action via positive allosteric action. *Benzodiazepines* Binding site is *between an α1 and the γ2 subunit* Increase *frequency* of Cl- channel opening *"Z-drugs" * Def = nonbenzodiazepine drugs with effects similar to benzodiazepines. These drugs can be used in the treatment of sleep problems. Bind to benzodiazepine BZ-1 (omega 1) receptor Appear to require an *α1 subunit*, which may be related to some more specific (like not anticonvulsant) effects *Barbiturates* Not as clear, bind to multiple isoforms in a separate than benzos/"Z drugs" site Also may block excitatory neurotransmitters Increase *duration* of Cl- channel opening

3 medications that are most implicated for GAD

GAD (and depression) Buspirone Venlafaxine - SSRI Paroxitine - SSRI

Perhaps the biggest risk factor for Bipolar Disorder

Genetic link identical twins -- 90% link!

PTSD Symptom: Negative changes in cognition and/or mood How does this manifest

Just get the general gist: Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, not to other factors such as head injury, alcohol, or drugs). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined"). Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Steven-Johnson's syndrome is a very serious side effect of what medication? What is the presentation?

Lamotrigine -treats chronic bipolar disorder depression Getting a rash is lamo Rash -- very serious

Why are benzos safer than barbiturates?

Less likely to stop breathing.

Big 3 DDx for Depression

MDD MDE (Major depressive episode) Bipolar disorder If someone is depressed, BEFORE you Dx them with MDD, you need to make sure there have been no episodes of mania or hypomania (which would lead you to bipolar DO) With Bipolar I disorder, they usually are depressed 6X more often than they are manic. With BP-II, there's 30:1 depression and hypomania ratio.

+++++ For treating any type of anxiety disorder, including Panic DO, you should use *SSRIs*. On the exam, it is likely that he will put use specific names. -What are 3 big ones you should be able to recongnize? -Mechanism to know: They decrease activity in what part of the brain?

Main: *Sertraline*, *Paroxetine*, *Fluoxetine* (others: fluvoxamine, citalopram, escitalopram) Mechanism: Turn down the *locus ceoruleus* so less NE. Also blocks 5HT reuptake obvi. > Take about 2-3 weeks to start working.

+++++ 5 Major TCAs (*CANDI*) and bad side effects TCA MoA

Mnem: *CANDI* -- "-ipramine" or "-triptyline" 1) Amitriptyline 2) Imipramine 3) Nortriptyline 4) Desipramine 5) Clomipramine *Low therapeutic index, may be lethal in overdose*: *Arrhythmia, Convulsions, Coma* Mechanism of action: *block reuptake of serotonin and norepinephrine* (*SNRIs*) Major Uses: not so much anymore Chronic neuropathic pain - most common OCD - Clomipramine used to be drug of choice before the SSRIs Migraine prophylaxis Insomnia - not recommended generally

The locus ceoruleus is a nucleus located in the pons that is responsible for making and releasing what NT? This produces what effect?

NE Produces fear/anxiety Player in anxiety DOs and PTSD

Should you ever use a benzo for PTSD?

NO!

16yo male brought in to clinic by mother for "counting everything" He admits to feeling driven to count objects around him, like chairs, cars and even bricks. He is embarrassed about this and appears anxious. States he has to do it or "something bad will happen to my family." -What is the proper Dx? -Effective pharmacologic treatments for this condition include which of the following: a. Lithium b. Haloperidol c. Bupropion d. Clomipramine e. Methylphenidate

OCD D- Clomipramine (remember -- clomipramine is what NMBE likes to ask about) SSRIs / Venlafaxine are also great.

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal) Infection produces symptoms that closely resemble what psychiatric disorder? These pts commonly have ___ (<- behavior).

OCD With tics

Mania vs Hypomania

One KEY way to tell is if behaviors would be seen as odd to only friends (and strangers would think they're just an uppity person) or if strangers would even be like whoaa this dude is on meth or something. Hypomania is a mere departure from how one normally is. So it's subjective. A gut feeling. So if in a vignette during the up episode, it says they are productive, their boss is like great job, etc -- good functioning so probably hypomania. Hypomania = mania lite; *4* days of 3 or more *DIGFAST* sxs. Change in functioning uncharacteristic of the person and observable to others *NOT severe enough to cause significant impairment in functioning, does NOT require hospitalization, and NO psychosis* *Considered to be good for creativity and productivity* since no real impairments. e.g., Schuman (composer) wrote all of his stuff during hypomanic episodes. So why is it a problem and in the DSM? Because hypomanic people tend to crash; or they keep going up into mania. Mania = *7 * days of 3 or more *DIGFAST* sxs, might have psychotic features in which they would need hospitalization.

+++++++ *Buspirone* -- only approved for what DO? ___ partial agonist How quickly does it start working?

Only used for GAD, but it's 2nd-line tx, behind SSRIs, because it does not treat depression or other anxieties. 5HT Takes a while: 2-6 weeks

When might you want to use Electroconvulsive therapy (ECT); What is the most dangerous part of it? Can you use it as first-line?

Overall, ECT is helpful for any mood problems -- reduces frequency & occurence of depressive episodes, manic episodes, and hypomanic episodes. It's the absolute most effective and fastest treatment for depression, ESPECIALLY if the pt is having associated psychotic sxs. Don't want to use it first line because there is a slight danger, but only from the anesthesia. It is also really good for Bipolar DO.

*Sertraline* and *Paroxetine* (SSRIs) are now FDA approved for being particularly good at treating what disorder?

PTSD

Small hippocampi associated with ___; Atrophy of hippocampi is seen in pts with ___.

PTSD depression

19yo female reports 6 month h/o episodes of sudden onset of feeling "dread and doom", increased heart rate, nausea, diarrhea, SOB, "tingling all over" and "feeling like I'm out of my body." Episodes last 5-20 minutes. She is frightened by them and worries about when the next one will happen. -What is the proper Dx? -Which of these is the best first line treatment? a) Carbamazepine b) Thioridazine c) Propranolol d) Paroxetine e) Phenelzine

Panic Disorder D- Paroxetine (SSRI)

PTSD Symptom: Avoidance

Persistent avoidance of stimuli associated with the traumatic event

+++++ What *PART OF THE BRAIN* is most responsible for anxiety? What is the role of the *prefrontal cortex* in the anxiety response? What is the role of the *pons* in the anxiety response?

Primarily the *Amygdala* -- too much activity; way too sensitive to possible stressors; amygdala sees non-threats as potential threats ==> inapproproate fear response / Symp NS activation. The amygdala is especially the central player in Panic DO, as well as PTSD. Anything with excessive fear would involve the fear center of the brain. Also involved are: prefrontal cortex (puts the brakes on the amygdala -- helps you evaluate and think about the stressor), anterior cingulate cortex, ex. The Pons contains the *locus ceoruleus* which makes NE, the primary NE responsible for the anxiety response.

Main treatment for Panic Disorder? When are benzos implicated?

Remember Tony Soprano? He got Prozac for both depression and panic attacks. SSRIs -- *start low and go slow* > want to start with a small dose. > calms down locus ceoruleus ==> less NE. Combine this with CBT. Decrease activity of amygdala, etc. Benzos are appropriate for a few treatment plans and conditions, such as *rare/ occasional PAs, early in combination with an SSRI (but wean off), and in the ER to control a PA*. Benzos are at high risk for addiction with panic disorder, but they're good because they will stop a PA in its tracks, though it might not even kick in on time.

Mirtazepine -*M of A* -- important and unique -- increases what 2 NTs? Agonist of what receptor? -MAIN SE -particularly implicated if you want to avoid what common SE of SSRIs?

Remeron Antidepressant alpha 2 agonist -- increases serotonin and NE implicated if you need to avoid GI issues. Makes you gain weight tho Sedating

+++++ *Flumazenil* blocks effects of ___ and ___ Downside: Can induce the worst of the worst sxs of withdrawal from ___. Works thru competitive antagonism with what receptor?

Reverses effects of *Benzos* and *Z-drugs*. Downside: In benzo-dependent pts, Flumazenil can induce severe benzo w/drawal, including seizures. Competitive antagonist of GABA receptor, which both benzos and Z-drugs bind to. (Does NOT reverse effects of alcohol, barbs, anesthetics, etc.)

Vilazodone (Viibryd)

SSRI and 5HT1a partial agonist Minimal weight gain Almost no sexual SEs

Sadness in depression vs sadness in grief

Sadness in grief is pretty much limited to missing the person. Sadness in depression is about many things.

MAO Inhibitors with SSRIs can result in

Serotonin Syndrome

+++++ Acute mania -- 3 main medications (*CVL*) Bipolar Depression - 2 chronic tratments (*L & L*) Why is *Lithium* the golden standard tx? It reduces risk of what?

So you can see why Lithium is the golden standard -- it covers both mania and depression. Stabilizes your mood. Lithium reduces *risk of suicide*!

Which Anxiety DO is characterized by fear of scrutiny, humiliation, or embarrassment in >1 social situations? How do you treat this DO? How do you treat "Performance Only" type?

Social Anxiety DO > Marked fear or anxiety about >1 social situations in which the person is exposed to possible scrutiny by others > Essentially is fear of scrutiny, humiliation or embarrassment > May be "Performance only" or generalized > May have associated panic attacks or lead to social avoidance > Severe forms overlap with Avoidant Personality D/O Treatment: *SSRIs* Beta-Blockers good for performance type.

Obsessive hair-pulling

Trichotillomania

Separation Anxiety Disorder -Diagnostic criteria -*Treatment*

Usually in kids (after age 3-4) -- fear of separation from parents; but can occur in other caregivers and even in adults. • Excessive distress when anticipating/experiencing separation from parents. • Persistent and excessive worry about losing them or possible harm to them • Reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. • Frequent complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from them occurs or is anticipated. Treatment: *make them go to school* (CBT/exposure tx)

Bupropion -*M of A* -- important -- (unique) -drug class -unlike SSRIs, it does not have implications for ___.

Wellbutrin NDRI NO SEXUAL SEs NO WEIGHT SEs No implications for anxiety

Depression with Atypical Features (5)

When it's clearly depression, but with odd features. Things that are "atypical" in depression pts. The big 5 are: With Atypical Features -Reactive to pleasurable stimuli (ie, feels better in response to positive events) -Increased appetite or weight gain -Hypersomnia (eg, sleeping at least 10 hours per day, or at least two hours more than usual when not depressed). -Heavy or leaden feelings in limbs -Longstanding pattern of interpersonal rejection sensitivity

Why is ETOH so common in anxiety DOs, especially PTSD and Panic Attacks?

You drink a little to reduce that little anxiety you have before going to a party, and it works of course. Magnify that anxiety x50 for people with panic attacks or ptsd and if they drink enough, that anxiety will go away. It's a temporary fix, but it does work. Maybe can get some sleep for a few hours, or shut out bad memories. But on the downside, when they stop drinking and go through alcohol w/d, the anxiety is a lot worse than it originally was.

Carbamazepine -treats what?

acute mania in bipolar DO

Citalopram -Most dangerous SE, recently discovered.

celexa Inhibits Cytochrome P-450 2D6 - weak Side effects: PROLONGS *QTc Interval* GI - nausea/vomiting/diarrhea SEXUAL (less than paxil and prozac)

Carbamazepine -- Don't take if ...(important contraindication)

Don't take if on other medications. So many interactions. It even metabolizes itself.

*Barbituates*: -enhance sythesis of ___, so contraindicated in pts with ___. -induce ___ enzymes, making them have many drug interactions

-increases production of porphyrins, so contraindicated in pts with acute intermittent poryphyria, or other porphyrin related diseases. -All of them induce P-450 enzymes, so be mindful of drug interactions.

+++++ *Valproate* -treats what? -2 forms it comes in -XX *major contraindication*

-acute mania in bipolar disorder -Divalproex (Depakote), Valproic Acid (Depakene) -SE: birth defects; don't take if pregnant

*+++++* -A manic episode must last ___ days or more. -A hypomanic episode must last at least ___ days, and not more than __ days. -Mania -- Must have 3-4 of the *DIGFAST sxs* -- what are the DIGFAST sxs?

*7 days or more* (i.e., at least a week) -- Manic episode Around 4-7 days -- hypomania --- But if pt requires hospitalization / has psychotic features, it's mania no matter what. *"Remember this for the purpose of your test"* -- "If it's 6 days, 23 hours, and 53 minutes, it's not a manic episode." Not really the case in real life, but for the purpose of the test it is. Or *ANY duration if hospitalization is required*. Presence of 3 of the following sxs (or 4 if mood only irritable) and the Symptoms are severe enough to cause significant impairment of functioning, require hospitalization, or presence of psychotic symptoms. Not due to general medical condition or substance abuse or medication. *DIGFAST*: D - *Distractibility* - poor concentration I - *Irresponsibility* - involvement in pleasure-seeking activities showing poor judgment, usually dysfunctional - sexual indiscretions, reckless driving, spending sprees, sudden traveling, foolish business investments. G - *Grandiosity* - inflated self-esteem F - *Flight of ideas* - racing thoughts A - *Activity* (inc. goal directed activities - initially functional and often useful, social, sexual, work, school) or psychomotor agitation. S - *Sleep* - decreased need T - *Talkativeness* -- Pressured Speech (a tendency to speak rapidly and frenziedly, as if motivated by an urgency not apparent to the listener)

Bipolar Disorder Differential Diagnosis -- things to rule out: -what *medication* class often leads to bipolar disorder sxs? And what SPECIFICALLY can they induce? -What is *Schizoaffective DO*, compared to Bipolar Disorder?

*Antidepressants* -- can suddenly switch depressive episode to a manic episode. > Bigtime misdiagnosis; you need to make sure that a person's depression is not part of Bipolar DO. > So if you give a depressed pt antidepressants and they report sxs of a manic episode -- Oops! Messed up! Turns out they have Bipolar DO. Schizoaffective DO: > It's in the name! -- "schizo" (schizophrenia; departure from reality) + "affective" -- mood symptoms. > KEY is *must have 2 weeks of psychosis in absence of mood symptoms*. > Characterized by the presence of concurrent *mood symptoms* (depression, mania, or hypomania) and *psychosis/delusions* (hallucinations, delusions, appearing sort of fixated in their own bizarre thoughts such as special powers or 6th senses that others don't have). > But at least 2 weeks of purely psychotic with no mood symptoms is the key. If pt never has that pure psychosis episode, then mood problems are still the focus and you would say Bipolar with psychotic features.

Therapeutic treatment for anxiety DOs

*CBT* -- *when in doubt, choose CBT*. CBT is a good choice for most treatable DOs b/c it includes cognitive AND behavioral therapy. CBT is better than medicine for OCD, and EQUALLY AS EFFECTIVE for other anxiety DOs. It actually changes the brain permanently -- for example, anxiety pts have lower amygdala activity after CBT

Venlafaxine (Effexor) -drug class -important metabolite -Worst side effect? (unique)

*Desvenlafaxine* (Pristiq) (has "venlafaxine" in the name; is an active metabolite, approved by FDA for depression. *Increased BP*

PTSD Symptom: Arousal and Reactivity -Due to elevated levels of *what NT*? -Presentation

*Norepinephrine* Behavioral clues: > Sits in the back of the waiting room > Eyes scanning room/hallway > Turns to noises > May want door open or sit in chair facing door > Leg tapping > Anxious or intense appearing

+++++ -What is the main *NT* responsible for anxiety? -It is made and relased by *WHICH PART* of the *PONS*?

*Norepinephrine*, made by the *Locus Ceoruleus*, located in the *Pons*.

Bipolar I DO -- What is the ONE diagnostic criteria?

*One manic episode* -- THAT'S IT Do *NOT* need major depressive episode for diagnosis, but almost always develop it subsequently Normally, a pt won't just have 1 manic episodes and the rest hypomania. Usually have either/or. If you've ever had a manic episode, you're Type I

+++++ Best kind of therapy for PTSD This therapy takes advantage of what component of learning theory? Medication treatment options of PTSD: 3 main ones One of them is particularly good at treating sleep problems and nightmares. *2 of them SSRIs *have recently been *FDA approved* for *treatment of PTSD*.

*Prolonged Exposure Therapy* Takes advantage of extinction -- you extinguish the learned associations by exposing them to it, producing a new conditioned response and getting rid of the old one. uses imaginal and invivo exposure in addition to relaxation focused on helping the patient habituate to the trauma memory/feelings Medications: 1) *SSRIs* -Specifically sertraline and paroxetine 2) *Prazosin* -reduces sleep problems and nightmares

Describe risk factors for completed suicide (MNEM) This is an actual scale, where you check off yes or no for each of the 10 risk factors and count them up.

*SAD PERSONS* S: Male sex A: Age (<19 or >45 years) D: Depression dx P: Previous attempt E: Excess alcohol or substance use R: Rational thinking loss S: Social supports lacking O: Organized plan N: No spouse S: Sickness

MAO Inhibitors -4 major MAO inhibitors (*SPIT*) -Which one specifically targets MAO-B?

*SPIT*: 1) Selegeline (Patch) 2) Phenelzine (funnelzine -- funnel in a wine bottle to pour it) 3) Isocarboxazid (BOXed wine) 4) Tranylcypromine ("try a sip of wine") *Selegeline* targets the MAO-B. Increase *Serotonin*, *Dopamine*, and *NE* in nervous system. Compare MAO-A and MAO-B: MAO-A breaks down all 3. MAO-B is specific to dopamine degradation.

A major incovenience of MAO inhibitors is that they prevent the breakdown of ___, a substance found in aged cheeses, wine, and beans.

*Tyramine*

Which reinforcement schedule is the most effective for learning to like something? (e.g., gambling uses this)

*variable ratio* schedule a response is reinforced after an unpredictable number of responses. This schedule creates a steady, high rate of responding. Gambling and lottery games are good examples of a reward based on a variable ratio schedule.

*Trazodone*: -*how does it work*? (unique) -*mostly used to treat what*? -important SE

-Blocks serotonin degradation receptor to inc. serotonin -primarily used for *insomnia*, as a sleep aid. -Priapism (prolonged erection) is a rare but important side effect.

OCD treatments: -Specific CBT method (you know about this!) -medication: SSRI or *___*. -If comorbid Tourette's, you would also prescribe a ___ medication.

-Exposure-Response Prevention (ERP) -SSRI or *Clomipramine* ^ Clomipramine not used often in real world but often on NBME -Add a *neuroleptic* if comorbid Tourette's or treatment refractory. Usually risperidone.

+++++ When do people ACTUALLY have Panic DO vs just panic attacks? What is a common ER presentation of a panic attack? Use Tony Soprano as a mnemonic/example.

CRITERIA: 1) At first, they have to happen at unexpected times and be recurrent. *RECURRENT and UNEXPECTED/ RANDOM* is the rule. • e.g., "It happened when I was walking out of church, I didn't even see it coming." • *"Common in vignettes"* -- "Felt like I was going to die!" • They are RANDOM surges of panic with *NO CLEAR TRIGGER*. • HOWEVER -- Over time, thier panic attacks will occur in a pattern, with particular and expected triggers, like how Tony Soprano eventually realized that interactions with his mother often preceeded them. But at first, they MUST be unexpected, also like Tony -- happened to him with the ducks in his back yard. 2) Has to negatively affect their *lifestyle* in some way. Usually in the form of fear of another PA. *"Common ER Presentation in Test Question Vignettes"*: 2 buzz terms: (1) "*pt thinks thinks they're having a heart attack* due to chest pressure and (2) "*I though I was going to die"*. Also hyperventilation, dizziness, etc. *When is it probably NOT Panic DO?*: You can have panic attacks with SAD, GAD, PTSD, hell, even depression. Learned something new -- *PANIC ATTACKS ≠ PANIC DO*. Has to meet those criteria. If you get only have attacks before giving speeches, it's probably social anxiety DO. If you get a panic attack before going outside, probably agoraphobia. If a grown adult has a random, sudden onset of severe panic attacks but was fine before, it is actually USUALLY a medical condition.

A psychiatrist is treating a PTSD pt using an evidence-based therapy. The psychiatrist helps the patient identify natural emotions and connect thoughts and feelings. Overall, the therapist is focused on helping the patient examine their thinking related to the trauma. What type of therapy is being used?

Cognitive Processing Therapy (CPT) alter how you think and process things, including your own emotions.

*Cyclothymic DO* -- Diagnostic Criteria

Cycles of hypomanic symptoms but never met criteria for hypomanic episode and depressive symptoms (but never met criteria for major depressive episode) with duration of 2 years Alternating periods or hypomania and mild to mod depression -- so never quite meet full mania or full depression; numerous periods with either for two years, can have symptom-free period, but not for more than 2 months

*Duloxetine*: -drug class -main SE -recently implicated for pain from what other disease?

Cymbalta SNRI MainSE: Nausea Recently implicated for *D*iabetic neuropathy pain

+++++ In general, what is the type of psychotherapy that is most effective for the treatment of anxiety disorders? a. Insight-oriented Psychotherapy b. Interpersonal Therapy c. Dialectical-Behavioral Therapy d. Cognitive-Behavioral Therapy e. Psychodynamic psychotherapy

D- CBT Know this!!!

SSRIs and Bipolar

DON'T USE! Can make bipolar worse. This is why you need to check for hx of manic episodes in pts.

At least one of what two depression sxs are required for dx? Time course for dx? What are the other 7 sxs to recognize, grouped by physiological effects (4) and cognitive effects (3) *MNEM: SIG E CAPS*

Depressed Mood and/or Anhedonia are required. Must be present on msot days for at least 2 weeks to be a major depressive episode. Other 7: see IMAGE MNEM: *SIG E CAPS* S - Sleep disturbances (↓ hours, early morning insomnia, not rested; sometimes too much sleep) I - Interests (loss), no pleasure, anhedonia G - Guilt, hopelessness, worthlessness E - Energy, fatigued, tired C - Concentration, forgetfulness, inattentiveness, indecisiveness A - Appetite/weight (decrease/increase) P - Psychomotor status (agitation or retardation) S - Suicidal, recurrent thoughts of death

*+++++* This will help you on the test. Hypothyroidism is a very common cause of ___

Depression This will likely show up on test so look for it. Very often, once you treat hypothyroidism, depression sxs go away, even w/o antidepressants

2 main comorbidities with PTSD

Depression Alcohol Abuse both are secondary sxs (caused by the primary symptom) -- need to treat primary symptom